(6.14) Storm of Paranoia

Thursday, May 9, 2024

1:05 PM – 1:20 PM CDT

Location: ePoster Showcase, Empire Ballroom Foyer, Level 2

Submitter(s)

Larry Liriano, MD

Endocrinology Fellow
Larkin Community Hospital
Miami, Florida, United States

Introduction : Graves’ disease is the most common cause of hyperthyroidism accounting for 60% to 80% of hyperthyroid cases. The overall prevalence of hyperthyroidism in the United States is 1.2% with an incidence of 20/100,000 to 50/100,000. It is most common in people ages 20 to 50 years and more common in women. Classic symptoms and signs include tremors, heat intolerance, weight loss, anxiety, palpitation, oligomenorrhea, fatigue, atrial fibrillation, sinus tachycardia, muscle, and brisk reflexes. Clinical diagnosis is not at all obvious in some cases and may include infrequent symptoms like severe muscle weakness or sudden changes in mental status including severe psychosis. Antibodies to TSH-Receptor-Thyrotrophin receptor antibody (TRAb) with low TSH and high FT4, FT3, or T3 are specific and confirmatory.

Case(s) Description : A 60-year-old man without past medical history was brought to ED escorted by police offices after a heated confrontation with his neighbor secondary to persistent paranoia and anxiety. ED physician recommended involuntary admission under Baker Act and psychiatry evaluation. Associated signs and symptoms: Pertinent negatives: abdominal pain, ataxia, chest pain, dizziness, headache, shortness of breath, vertigo. Current symptoms: anxiety, paranoid, flight of ideas, and confusion. BP 134/78 mmHg, pulse 89, temp 98.1 F, BMI 18.4 kg/m2. Urine toxicology negative for barbituric, benzo, cocaine, MTD, PCP, THC, opiates. Ammonia: < 9, ETOH < 10, electrolytes unremarkable, GFR 110, AST 28, ALT 27, TBILI 0.3. TSH < 0.015, FT4: 6.06 ng/ml, FT3: 12.5 pg/ml, T3: 4.60 ng/ml. Head CT without and with contrast: No acute intracranial hemorrhage, midline shift, or mass effects. EKG: Sinus, HR 68, no ST elevation, or inversion. Physical examination: tenderness and enlarged thyroid gland and persistent flights of ideas but oriented in person, space, and time. Based on current findings, patient was started on propylthiouracil 50 mg TID and increased to 100 mg TID after 3 days, propranolol 10 mg BID, and dexamethasone 6 mg IV as single dose. We recommended TRAB abs: 3.25 IU/L, TSI: 4.37 IU/L, and TPO abs: 82 IU/L. Seven days after of admission, patient mental status improved and discharged to inpatient psych facility for subsequent discharge home. Labs before discharge: FT3: 10.3, FT4: 3.76, and T3: 2.43.

Discussion :

TSH level has been included as part of the initial work-up at ED in patients with neurological-psychiatry sign or symptoms therefore physicians are able to diagnose overt hypo and hyperthyroidism within minutes after arrival the hospital. In patient with excessively elevation of FT4, propylthiouracil can be use as initial therapy in overt hyperthyroidism because quicker onset of action and inhibit the peripheral deiodinase enzyme decreasing peripheral conversion of T4 to T3. Beta blocker like atenolol or propranolol will help to decrease adrenergic symptoms until T4 and T3 decrease. The definitive therapy if no contraindication includes RAI or surgery. Physician must be aware about non classic symptoms of overt hyperthyroidism to prevent thyroid storm which is the more fearsome complication related to this disease with a substantial mortality of 10-30%.